1396090387 NPI number — COLORADO NEUROLOGY AND EPILEPSY CLINIC, PLLC

Table of content: (NPI 1396090387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396090387 NPI number — COLORADO NEUROLOGY AND EPILEPSY CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO NEUROLOGY AND EPILEPSY CLINIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1396090387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
554 MOONMIST CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLANDS RANCH
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80126-5693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-470-9553
Provider Business Mailing Address Fax Number:
720-583-6796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 W. COUNTY LINE RD
Provider Second Line Business Practice Location Address:
STE 320
Provider Business Practice Location Address City Name:
HIGHLANDS RANCH
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80129-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-470-9553
Provider Business Practice Location Address Fax Number:
720-583-6796
Provider Enumeration Date:
07/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CLEMMONS
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
SEAWELL
Authorized Official Title or Position:
OWNER/SOLE MEMBER
Authorized Official Telephone Number:
303-470-9553

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  50255 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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